The Cost of Costly PrEP
For many patients, PrEP is not covered by their insurance, forcing them to pay high costs or forgo the medication altogether.
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- Delays in PrEP dispensation are associated with higher odds of acquiring HIV infection.
- Lowering barriers to timely PrEP uptake could reduce HIV incidence.
HIV affects approximately 1.2 million people in the United States, with as many as 40,000 new infections diagnosed every year. Consistently taking PrEP (pre-exposure prophylaxis) medications substantially reduces the risk of contracting HIV from unprotected sex or unsafe injection practices. However, PrEP is highly underused, due in part to cost and access barriers among high-risk populations.
Li Tao and colleagues examined the insurance-related drivers of low PrEP uptake among nearly 400,000 individuals in the U.S. They used pharmacy and insurance data to analyze reasons for insurance companies rejecting medication requests for PrEP. Delays in PrEP initiation were measured by the number of days between medication requests and pick-up. The team then used health records to examine the effects of delays in PrEP initiation on new HIV infections among the same study population.
Insurance interference played a large role in PrEP initiation delays. The figure below illustrates the most common reasons insurance plans rejected patient requests for four FDA-approved PrEP medications. Most often, patients found their prescribed medications were not covered, which forced them to pay high out-of-pocket costs or forgo the medication altogether. Some patients reached refill limits that prevented them from collecting PrEP. Others had to endure delays while their insurance plan went through the prior authorization process to confirm that the patient’s doctor would not prescribe a less expensive medication option.
Insurance company interference can lead to serious public health consequences. For example, new HIV cases were higher among individuals whose prescriptions were never filled by the pharmacy, compared to those who received their prescription. Even short delays (1 to 7 days) in filling PrEP prescriptions were associated with an increase in subsequent HIV infection.
The authors highlight the importance of upholding and fully enforcing current laws that reduce cost and access barriers to PrEP. One such example is the 2024 Affordable Care Act mandate that requires insurance companies to cover oral and injectable PrEP medications without asking patients to share in the payment. It also prohibits companies from pressuring patients to choose less expensive formulations. Insurance companies have multiple mechanisms for blocking recommended care. Continued policy efforts to make HIV prevention options available across the population are necessary.
